Incident Sharing Practices

Transcription

1 Incident Sharing Practices Fritz Näumannǀ Euro Chlor WCC GST Safety Workshop Sao Paulo November 14, 2014

2 WCC Incident Reporting Theory Objective: Learn from experience => near misses should reported Scope: Incidents associated with chlorine production, distribution or use WCC incident reporting is coordinated with the regional chlorine producers associations e.g. ABICLOR, CI, JSIA to produce WCC database. 2

3 WCC Incident Reporting Criteria technical interest : learning form experience serious injury: lost time (employee or contractor) property damage in excess of EUR 100,000 media response authorities involved leak > 5 kg chlorine 3

4 WCC Incident Reporting Format EXCEL sheet available on the EuroChlor website Key elements to be included: description, consequences preventative measures, important for the learning process! Pictures or drawings to better illustrate the event. 4

5 WCC Incident Sharing Form Type of Activity Bleach maker Chemical Industry Cl2 consumer Chlorine producer Other Packager Swimming pool Water treatment Bulk storage Cl2 absorp. (Off)Loading Other Pack Pr gas PrLq L PrLq V Transport Unknown User Primary Cause Event related activity Bulk storage Chlorine Absorption - Hypo Production Loading off-loading Other Packaging Operation Production Chlorine gas Production Liquid Chlorine Liquefaction Production Liquid Chlorine Vaporisation Transport Unknown Chlorine consumer Quantity released Unknown 0 <= 1 kg <= 5 kg <= 10 kg <= 100 kg <= 500 kg <= 1 t <= 5 t <= 10 t >10 t Equipment Cylinder Cylinder / bottle ( kg) Drum Drum ( kg) / ton container Hose Hose / Flexible Other Other Pipe Pipework Prod. vessel Production (process) vessels Pump Pump / compressor Storage vessel Storage tank Transp. vessel Rail or road tanker or ISO container Unknown Unknown Valve Valve Electrical Electrical outage Mixing Erroneous mixing Training Human error: Lack of Training Procedure Human error: Procedure Not Applied Design Initial Process Design Error Instrument Instrumentation failure Explosion Loss of Mechanical Integrity due to violent chemical reaction / explosion Corrosion Loss of Mechanical Integrity due to corrosion/erosion Force Loss of Mechanical Integrity due to external forces (collision, ill will, weather...) Maintenance Loss of Mechanical Integrity due to maintenance procedure error Machine Machinery failure Gasket Mat. Material Gasket Failure Gasket Mech. Mechanical Gasket Failure Modif Modified Process Design Error Not ident No Identified Primary Cause Other Other Heating Overheating Pressure Overpressurisation Structure Structural support failure Constr Mat Unsuitable Material of Construction 5 Transport activity Collision with other vehicle Equipment leak Loosing movement control Shunting yard incident (rail) Media Response No Local National International WCC GST Sao Paulo November 14, 2014 Incident Sharing F. Näumann Mode of shipment Water Pipeline Rail Road Product Chlorine HCl Hydrogen Hypo Other

6 WCC Incident Sharing Form (2) Type of Activity Bleach maker Chemical Industry Cl2 consumer Chlorine producer Other Packager Swimming pool Water treatment Quantity released Unknown 0 <= 1 kg <= 5 kg <= 10 kg <= 100 kg <= 500 kg <= 1 t <= 5 t <= 10 t >10 t Product Chlorine HCl Hydrogen Hypo Other 6 WCC GST Sao Paulo November 14, 2014 Incident Sharing F. Näumann

7 WCC Incident Sharing Form (3) Primary Cause Electrical Electrical outage Mixing Erroneous mixing Training Human error: Lack of Training Procedure Human error: Procedure Not Applied Design Initial Process Design Error Instrument Instrumentation failure Explosion Loss of Mechanical Integrity due to violent chemical reaction / explosion Corrosion Loss of Mechanical Integrity due to corrosion/erosion Force Loss of Mechanical Integrity due to external forces (collision, ill will, weather...) Maintenance Loss of Mechanical Integrity due to maintenance procedure error Machine Machinery failure Gasket Mat. Material Gasket Failure Gasket Mech. Mechanical Gasket Failure Modif Modified Process Design Error Not ident No Identified Primary Cause Other Other Heating Overheating Pressure Overpressurisation Structure Structural support failure Constr Mat Unsuitable Material of Construction 7 WCC GST Sao Paulo November 14, 2014 Incident Sharing F. Näumann

8 Incident Sharing The Practice 8 WCC GST Sao Paulo November 14, 2014 Incident Sharing F. Näumann

9 ABICLOR ABICLOR INCIDENT REPORTING (1) EVENT DATE: /_(2) CITY (3) STATE: (4) PLACE OF ACCIDENT: TIME: (5) PRODUCER: (6) CARRIER: (7) COSTUMER: (8) PRODUCT: (9) AMOUNT INVOLVED: (10) AMOUNT RELEASED: (11) DESCRIPTION OF EVENT: (12) DAMAGE/CONSEQUENCE: - MATERIALS/EQUIPMENT: - PERSONAL: - ENVIRONMENTAL: (13) CAUSE OF EVENT: (14) IMMEDIATE ACTIONS TAKEN: (15) PROPOSALS TO AVOID REOCURRENCE: 9 Date: / / WCC GST Sao Paulo November 14, 2014 Incident Sharing F. Näumann

10 ABICLOR Incident Sharing 10 WCC GST Sao Paulo November 14, 2014 Incident Sharing F. Näumann

11 Incident Sharing in USA / CI 11

12 Example of Intelex Form and Information Question 4, Incident Classificati on: Modified to include chemical burns in the on-site and off-site injury counts. 12

13 Incident Reporting However- incident reporting has basically stopped since 2004 Not really sure why when in doubt blame the lawyers Along with process safety the goal of the GST over the next few years will be to improve incident reporting Simplify format and provide a clear definition of what should be reported Get commitment from GST associations to provide information

14 Injury Statistics- North America number of incidents per 200,000 work hours 2,00 1,500 Total Recorded Incident Rate in North America Chlor-Alkali Facilities 1,00,500,

15 Incident Sharing EUROCHLOR 15

16 Incident Sharing - Conclusions & Questions Sound safety and environmental practices are the basis of our LICENSE TO OPERATE Are we really performing that good in some regions?? How can we revitalize incident sharing? 16 September 11, 2014 Edinburgh ǀ Safety Initiative ǀ F. Näumann

17 Incident Sharing Practices BACK-up slides 17

18 Euro Chlor Safety Initiative Fritz Näumannǀ Euro Chlor GAM Edinburgh, September 12, 2014

19 Euro Chlor Safety Initiative Sound safety and environmental practices are the basis of our LICENSE TO OPERATE Proactive approach of Euro Chlor towards SAFETY May 2013 Euro Chlor Safety Commitment Euro Chlor Safety Initiative September 11, 2014 Edinburgh ǀ Safety Initiative ǀ F. Näumann

20 European Chlorine Industry Safety Performance improvement trend reconfirmed in 2013 big spread of performance => further improvement potential 20 September 11, 2014 Edinburgh ǀ Safety Initiative ǀ F. Näumann

21 Euro Chlor Safety Initiative - Elements Enhance self-commitment of members Offer 3 rd party training for leaders Improve reporting & sharing of safety information Establish a self-audit tool Offer enhanced networking & experience exchange Encourage sharing of best practices & safety rules Offer support visits by Euro Chlor Build on existing industry and member programmes 21 September 11, 2014 Edinburgh ǀ Safety Initiative ǀ F. Näumann

22 Dutch industry programme Safety First Veiligheid Voorop Safety Leadership Culture Safety Management System Agree & report safety KPIs Emphasize workers training Networking, Communication (IT assisted) Sharing of Safety Information & Practices Responsability for Value Chain 10 September 11, 2014 Edinburgh ǀ Safety Initiative ǀ F. Näumann

23 AkzoNobel Life-Saving Rules 12 September 11, 2014 Edinburgh ǀ Safety Initiative ǀ F. Näumann

24 Lead on Geh voran BASF Safety Awareness Cards What do I want to Improve under my responsibility this year to prevent accidents, incidents and near-misses? How and when do I reward good safety work? Where in my area might the next accident happen? How do I react appropriately when someone doesn t behave safety/respect our Safety Rules? What percentage of my resources do I spend on safety in my area? 11 September 11, 2014 Edinburgh ǀ Safety Initiative ǀ F. Näumann

25 Euro Chlor Safety Initiative - How Focus on leaders: company executives, site/plant managers, EHS function Safety culture Offer support Encourage sharing information / best practices Peers assisting each other but also peer pressure Expect industry leaders to actively assist Build on existing programmes 25 September 11, 2014 Edinburgh ǀ Safety Initiative ǀ F. Näumann

26 Implementation Steps Communicate basic safety rules Check / adapt LTI data Select 3 rd party leadership seminar Design & roll-out self-audit tool Offer support visits to members sites Organize 1 st leadership seminar Sept 2014 Dec 2014 Jan Progress report at AGM 2015 Mid September 11, 2014 Edinburgh ǀ Safety Initiative ǀ F. Näumann

27 BACK-UP Incident Sharing in USA / CI 27

28 US Incident Reporting US Government Requirements The US government agency for personnel safety is OSHA The US government agency for releases of chlorine or other hazardous chemicals is EPA In the US personnel records of accidents are maintained but are not required to be submitted to the OSHA. Releases of chlorine or other regulated hazardous chemicals that are of a certain quantity or which may leave the facility property must be reported.

29 Injury Statistics- North America 2,00 1,500 Total Recorded Incident Rate in North America Chlor-Alkali Facilities 1,00,500,

30 US Incident Reporting Chlor-Alkali Industry Reporting Members of the Chlorine Institute report both personnel and chemical release incidents to CI staff via an online reporting system called Intelex All injuries reported except first aid cases (personnel injuries) Releases of chlorine or other CI mission chemicals reported (process incidents) The Performance Indicator Report and CI Safety and Environmental Awards based on this reporting

31 Example of Intelex Form and Information Question 4, Incident Classificati on: Modified to include chemical burns in the on-site and off-site injury counts. 31

32 Example of Intelex Form and Information Question 6, Incident Information: Modified to add a text box to indicate the number of years of experience of each injured person involved in the incident. 32

33 Example of Intelex Form and Information Question 10, Incident Information: Modified to add a dropdown list for Mode of Operation 33

34 Safety Data Use Performance Indicator Report For Chlorine Institute Members Only Published in late spring Purpose: Sharing information regarding chlorine incidents is critical to each member s overall success in reducing the frequency and severity of such incidents. A report on chlorine safety performance of the Institute membership shall be prepared and presented annually. Chlorine safety performance measurements include chlorine incident and related injury performance. -Policy on Chlorine Safety and Security Stewardship

35 Contents of Report Annual compilation of CI member safety performance: Comparison of actual performance with annual goals Listing of incident descriptions with CI severity ratings Historical trends in safety of CI members 35

36 Safety Alerts/Lessons Learned Safety Alerts based on information reported to CI Staff Member Exchanges

37 WCC GSTIncident Reporting WCC Global Safety Team (GST) Incident Tracking Program The GST seeks to learn about chlorine incidents and report about them in the GST newsletter so we can all learn from these experiences and minimize the risk of such incidents being repeated. The GST believes that the reporting of such incidents can also improve the technical recommendations published by WCC member associations.

38 Incident Reporting However- incident reporting has basically stopped since 2004 Not really sure why when in doubt blame the lawyers Along with process safety the goal of the GST over the next few years will be to improve incident reporting Simplify format and provide a clear definition of what should be reported Get commitment from GST associations to provide information

39 Chlorine events reporting General guidance The events reporting is coordinated with the other chlorine producers associations (like the Chlorine Institute) to produce the World Chlorine Council (WCC) database. All events to be reported would be associated with chlorine production, distribution, or use. The objective is not to build an exhaustive database, but to allow chlorine producers and users to learn from experience of these events; in consequence, the near misses having also a high learning potential should be included. The event report form (EXCEL sheet available on the CVn) should preferably be used and sent as soon as possible to the Euro Chlor secretariat. The key elements to be included are: description, consequences, preventative measures (most important part in the frame of the learning process). Pictures or drawings are also very useful to better illustrate the event. Criteria for reporting The most important criterion triggering the reporting is the technical interest (learning form experience), but other criteria, like the ones used in the process incident reporting of the Sustainable Development questionnaire, must also be taken into account: - serious injury (lost time) to one or more employee or contractor - property damage in excess of EUR 100,000 - media response - authorities involved - leak > 5 kg chlorine 39